Provider Demographics
NPI:1235570938
Name:WOODRUFF FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:WOODRUFF FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-465-0001
Mailing Address - Street 1:311 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4047
Mailing Address - Country:US
Mailing Address - Phone:918-465-0001
Mailing Address - Fax:918-465-0003
Practice Address - Street 1:311 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4047
Practice Address - Country:US
Practice Address - Phone:918-465-0001
Practice Address - Fax:918-465-0003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749100AMedicaid
OK1235570938Medicare UPIN